Advanced Amblyopia Treatment…for faster and better outcomes

Emily Cutcliff swim photoshoppedAt age 18, Emily is a bright and talented young lady. In her senior year of High School she is also on the school’s swim team, a sport that she could excel, even with no depth perception. Yes, Emily’s story begins with stereo blindness.

It was in June 2012 when I first examined Emily and learned that she had been originally diagnosed with Amblyopia (Lazy Eye) when she was 7 years old. As a little girl, her initial eye examination revealed a type of Amblyopia due to a significant difference in the refractive state of eyes. Her left eye was very farsighted and her right eye had no significant refractive condition. As a result, in these very formative years of her life, her visual brain shut down the input from her left eye resulting in subnormal vision…even with glasses. Her ophthalmologist at the time prescribed the standard treatment paradigm for her Amblyopia, full ophthalmic correction and occlusion therapy (an eye patch for her right eye). A review of her past records revealed that her visual acuity did improve in her left Amblyopic eye, but like many Amblyopic children who are prescribed occlusion therapy treatment, she never gained full visual acuity in the left eye plus she was without 3-D vision, she was stereo blind.

Emily is not alone as 1 in 30 individuals will have Amblyopia (3%). While this condition is totally preventable when detected in infancy, the majority of patients are identified after Amblyopia is established. When diagnosed in childhood, a common standard treatment is occlusion therapy – patching the “good eye”. However, as most doctors will attest, compliance is often a problem and even when acuity improves, it often does not remain once the occlusion is discontinued. Furthermore, even with improvement in visual acuity the patient will typically remain with a binocular dysfunction called “suppression”, rendering the patient “stereo-blind”. To make matters more bleak, due to outdated paradigms of treatment that rely on intervention within a “critical period”, as an amblyopic child get’s older, eye doctors will  often advise parents that there is little or nothing that can be done to treat the condition if the child is past 10 years of age.

So at age 18 Emily presented to me for care as a referral from her primary care optometrist, with reduced (best corrected) visual acuity ranging from 20/40-20/50 and stereo blindness. She wore a contact lens to correct her farsightedness on her left eye, prescribed by her referring optometrist. Yes, Emily knew she could not judge depth, but otherwise truly was unaware of what she was missing.

Once we had a diagnosis, our approach was an advanced amblyopia treatment paradigm based on what we know from the latest neuroscience about the visual brain and amblyopia. Studies show that there is placticity even in the adult brain when the emphasis in the treatment protocol is changed from monocular (patching) to binocular stimulation in office-based vision therapy. In addition, not only does this yield  better and faster results, but it is also much more enjoyable to the patient thereby eliminating compliance problems.

To help doctors understand this advanced Amblyopia treatment paradigm it was my pleasure along with Dr. Lindsey Stull and Dr. Tuan Tran to present to the Annual Michigan Vision Therapy Study Group on February 8, 2013. Our lecture entitled: Advanced Amblyopia Treatment for faster and better outcomes, can be downloaded in a pdf version by clicking the title or viewed in a slide show below. To see the slideshow stream in a video with music just click on the image below.

The advanced Amblyopia treatment protocol was prescribed for Emily. As a result, not only is she seeing nearly 20/20 in her left eye, but now she has 100% (40″- Wirt) on her distance stereopsis (3-D vision) testing. The conclusion of Emily’s Story is here:

Dan L. Fortenbacher, O.D.,FCOVD

15 thoughts on “Advanced Amblyopia Treatment…for faster and better outcomes

  1. Hi Dan, MFBFAre these done with stereo glasses or red green glasses?Since Saccades come first and pursuits second during development in humans, i.e focused attention then sustained attention, is that what you are trainingwith the MFBF?Thanks, August Date: Sat, 16 Feb 2013 03:18:56 +0000 To:

    • Thank you for your question Dr. Krymis. The principle of Monocular Fixations in a Binocular Field is usually done with a filter on only the one eye, that is the normally fixating eye. The goal is to break through the amblyopic’s brain adaptation of active inhibition of the amblyopic eye. Thus, by requiring the amblyopic eye to lead in the presence of the normally fixating eye, we disrupt the process of active inhibition and begin the process to “turn-on” binocular vision. It is not necessary to do this in any developmental heirarchy of saccades prior to pursuits. It is more important that the patient is engaged in something enjoyable.
      To see an example of this inaction in conjunction with the Perceptual Learning take a look at this video of our patient Caroline playing Wii Tennis in an MFBF mode.

  2. OK Dr. Fortenbacher, Caroline is wearing a red filter on the “bully eye”, What difference does it make if she were wearing a patch instead or scotch tape. I can’t tell by the video if she is wearing a prescription in front of the right good eye, but probably is. Thanks for your continued expertise. You are great at what you do. August

    • Dr. Krymis, thank you for the follow-up question on the Caroline MFBF Wii Tennis video. Yes, Caroline is wearing her habitual Rx, which in addition to her right eye esotropia, she also has a significant anisometropia too. But, the purpose of MFBF is to allow the amblyopic eye to lead, ie to not be suppressed by the normally fixating eye. Yes, we want her “bully eye” to allow her ambyopic eye to “play”. So, the “bully eye” is allowed to see the peripheral elements of the TV, but can not see the central parts which are seen by the amblyopic eye. Thus, MFBF is the bridge to binocularity by breaking through the process of active inhibition. If we just covered or did graded occlusion, there would no interaction with the two eyes. As a matter of fact, the recent research by Hess, et al, showed that graded occlusion (Bangerter foils) did no better than standard occlusion methods. Therefore, the Advanced Amblyopia Treatment paradigm works better than patching because we are breaking through the active inhibition process which is the fundamental nature of the etiology of amblyopia. Thank you for looking out for these kids!

  3. Hi Dan, Re your presentation and the NEW treatment for Amblyopia that is finally becoming in vogue including Hess, may I point out that this has been in the Optometric literature and Clinical Practice for over 20 years. I have 2 articles in the literature . 1)..Alternative Treatment for Anisometropic Amblyopic Patients: A Case Report (Optometry and Vision Development Vol. 24/Summer 1993 ) and the follow up 2)Treatment of Amblyopia without full Refractive Correction or Occlusion.(Journal of Behavioral Optometry Vol 6/1995 Number 1) Numerous lecture presentations COVD,AOA, Academy ,seminars and residency programs have enabled thousands of Amblyopic patients to have benefited from the vision training approach. Perhaps clinical trials can be undertaken to prove the efficacy of this approach.

    Best Regards, Arnie Sherman

    • Thank you Arnie for your comment. It is so good to see that this post caught your attention! Certainly it is thanks to our optometric giants in the field of vision development and vision therapy, like you, who have shaped the successful treatment protocols that many of us have adopted for decades…yes, even before we had the neuroscientists telling us why binocular VT was the best way to treat amblyopes! In fact, I recall sitting in on your 1995 COVD lecture! In addition, you might like to know that the Vol 6/1995 Number 1 JBO paper featuring you and Kelly Frantz was a big part of the back ground reading material that our resident was given to study in preparation for his portion of the lecture.

      Indeed, this is not “NEW” information to us, but in reality it is new information to the majority of young ODs and certainly to ophthalmology as a whole. While, the latest published research (2011-2012) by Hess, Levi and many others in the neuroscience community is long overdue it is imperative to this public health issue that we keep “beating the drum”. That is, just as you have been teaching, amblyopia is treated more effectively and more humanely when binocular vision therapy – not patching – is used as the mainstay in treatment…and now we have the “new” research to prove it, with hopefuly more on the way!

      I hope all is well with you in the Big Apple!

  4. Pingback: Advanced Amblyopia Treatment for Faster and Better Outcomes

  5. Hello Dan,
    My name is Andrew and I am a 28 year old male sufferer of amblyopia. I also have a slight strabismus of 3 prism diopters. I had a right eye infection just after birth, which is thought to be the cause of my amblyopia, but other than that my right (amblyopic) eye is physiologically normal. My best vision in my right eye is 20/40 corrected, while I am 20/15 corrected in my left eye. I spent 7 years in the military while never receiving treatment for my condition. Now that I am a civilian, I am going to school full time in order to gain acceptance into medical school. As I am having to read so much, my vision is increasingly frustrating me and I feel it to be very debilitating. I am highly motivated and desperate to receive help for my condition. I would like to be able to read without seeing sentences slant and drift away in my right eye.

    I came across a few articles you listed prior to finding this review. Specifically the one about video games, which is how I convinced my wife to buy me an XBOX 360 🙂 …After going through all the information you posted I am, for the first time, hopeful! Of course I want to start treating my condition now as I am scheduled to retake the MCAT this summer. You can probably guess why I need to “retake” my MCAT in the first place; I read too slow and my Verbal Reasoning score exposes this. So is there a way I can treat myself with this new paradigm? I receive my healthcare through the VA and they are extremely close minded about any adult amblyopic treatments. I am unfortunately on my own, but desperate and willing to do whatever it takes never-the-less. How would you advise someone in my situation to pursue treatment?

    I greatly appreciate your time!

    • Thank you Andrew for your heartfelt comment. The key to understand is that the new research is confirming what those of us have known in the field of developmental vision and vision therapy. That is, age is not a barrier to obtaining good results with office-based optometric vision therapy. The new paradigms discussed in my lecture are echoing the research that shows that the therapy techniques must involve binocular stimulation and also be engaging, such as in a video game. But, the treatment is not just playing video games! Sorry! What the research shows is consistant with what the neuroscientists have said in other areas of rehabilitative care, that is you must engage the patient is something that is relevant in order for the brain to develop the neural connections.

      So, while I wish I could give you a home-based solution for your condition based on your history, as you will find out in your own patient care, there is much more below the surface than the history. So, first inorder to the find the help you need, you must find a doctor who is trained in this specialty of vision rehabilitation. I encourage you to go to the website of the College of Optometrists in Vision Development, and click on the Doctor Locator to find a qualified doctor near you. Best wishes for your success!
      Dr. Fortenbacher

  6. Alas, there are no COVD doctors within 200 miles of me (I’d be willing to consult with one but could not make regular visits).

    I only recently realized that my “weak” eye is an amblyopic eye (now a -8; each time I get a new stronger prescription that eye just gets weaker and weaker). Scary. But I’ve also learned that there might be something I can do about it … even in middle age. I’m certainly motivated. But I guess I’ll have to cobble together some program for myself.

    I read your article and observations about monocular fixation with great interest. It makes sense. Like Andrew above I’ll be buying myself an xbox or some such thing (haven’t played “video” games since Pacman!), but I’ll look further into the fixation and engagement issues as well.

    Thank you!

    • Thank you Patrice for your comment. With the advent of modern telemedicine technology, after an initial diagnostic examination, many VisionHelp doctors offer home-based “Skype-type” vision therapy support. You may be a candidate. If you have further questions please contact our office.

  7. i have lazy eye i am 12 years old how can i get rid of my problem doctors tell me different thing you cant wear an eye patch anymore, you have ton wear an eye patch until 18 and they say there is nothing i could do else for my eye but i think any thing is possible so i havefaith that there will be another treatment for me oh and also my name is emily too

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s